Case History
A 50-year-old female without any comorbidities presented with a history of skin lesions
over the face, trunk, and limbs ([Fig. 1]) for 4 months with generalized weakness and weight loss over a period of 2 months.
On examination, there were multiple erythematous skin lesions on the face that coalesced
to form nodular plaque of varying sizes from 2 mm to 4 cm over the erythematous base
with mild scaling and yellowish black crusting. She also had hyperpigmented macules
over the trunk and limbs. Other findings were pallor and splenomegaly.
Fig. 1 Multiple nodular skin lesions over the face.
Workup
Complete hemogram showed a total leukocyte count of 80,000/mm along with shift to
left. Peripheral smear examination showed blasts with increase in myeloid precursors
and basophilia. Bone marrow aspirate revealed increased myeloid precursors with the
presence of all the stages of maturation (myelocytes, metamyelocytes, and neutrophils).
Blasts constituted around 86% of nucleated marrow cells. Karyotyping and fluorescence
in situ hybridization showed translocation t(9:22), confirming the diagnosis of chronic
myeloid leukemia (CML). Skin biopsy showed diffuse blast cell infiltration in the
superficial dermis ([Fig. 2A–D]).
Fig. 2 (a) Photomicrograph of bone marrow aspirate showing suppressed erythroid, myeloid, and
megakaryocytic series and replaced by blast cells; (b) photomicrograph of bone marrow biopsy showing diffuse sheets of large blast cells;
(c) photomicrograph of skin biopsy with dermis showing perivascular and diffuse infiltration
by large blast cells; and (d) karyotype of bone marrow analysis showing a Philadelphia chromosome.
Diagnosis
Based on the above investigations, she was diagnosed as a case of CML in blast crisis
with leukemia cutis as an extramedullary deposit. CML in blast crisis has a dismal
prognosis with a median survival of 9.4 months. Our patient finally succumbed to death
after 4 months of presentation. This case emphasizes the fact that a high degree of
suspicion and expertise is important for diagnosing such uncommon presentation of
common malignancies. Hence, early diagnosis of such rarer presentations helps in appropriate
treatment, which ultimately leads to better chance of survival and reduces the risk
of fatality.
Disclaimer
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In the form, the legal guardian has given his consent for images and other clinical
information to be reported in the journal. The guardian understands that names and
initials will not be published and due efforts will be made to conceal identity, but
anonymity cannot be guaranteed.
